North Coast: Gede

After most of our company from the US departed last week, E and I decided that we needed a little getaway… from our getaway. Seriously though, the last few weeks have been pretty stressful while we’ve been trying to figure out a lab-related plan of attack for the last few months of our stay. Plus your pipette muscles get sore after the 20,000th aliquot of the day so we just felt the need to get away from the house for a few days.

We settled on Malindi, a town about three hours north of Mombasa (the 'North Coast'), which has in recent years become somewhat of a hub for Italians. More on that later.

Some friends of ours in town helped us find a very cheap car rental place in Diani, and we headed up the coast on Saturday morning. Crossing the ferry was thankfully uneventful, and before too long, we were on the open road heading north. Our first planned stop was the ruins of an ancient Swahili town called Gede.

Gede was built in the 14th century by a Swahili tribe, and was quite prosperous for hundreds of years. The Swahili are a coastal tribe with territories from Somalia to Tanzania and were often the middle-men between Arab traders and inland African tribes. They converted to Islam through their interaction with the other traders and were among the wealthiest Africans because they controlled access to foreign goods. The influence of the Swahili culture has since diminished and several signs in Gede referred to the “Golden Age of Swahili Culture” as the 15th century. Gede, therefore, was built in this heyday.

By the 17th century, Gede was abandoned, either because of neighboring marauding tribes, or because the water table inexplicably dropped and the wells dried up. Regardless, the town was lost until the late 1800s, at which point it was lost again until about 1930. Very forgetful, those Kenyans.

During excavations of the site, archeologists uncovered a sophisticated, prosperous city. Fine china, Chinese money, Venetian glass, Spanish scissors, Indian iron lamps, and other items were found, indicating an expansive trade network through the Indian Ocean. The site has since been designated a national park and is protected from logging and such. Most of the remaining city is constructed from coral blocks; there was a large surrounding city that housed the lower and middle class, but their dwellings rotted away long ago.

E and I arrived and decided that for this kind of site, a guide would add a lot to the experience, so we found little Alphus, who proved to be as good of a guide as he was tiny. See below.



Here’s me in the main mosque (there are nine in the town):



We learned that the mosque was partitioned so that women sat on one side of the wall and men, including the iman, sat on the other. In order that the women could hear the main prayers, the Swahilis fashioned these echo chambers (that's the little alcove I'm standing in above).

The iman could recite into a small hole in the wall and his voice was amplified throughout the mosque. I made a small attempt with a very American “hello” before Alphus shoved me aside and performed a haunting call to prayer as we stood in the forest mosque. It was quite surreal.

A “pillar tomb”, unique to the Swahili Muslims:



The buildings are all named very descriptively: “The House of Scissors”, “The House of Chinese Money”, “The House of Cowries”, etc. based on where they found various artifacts. Since there is no written record of the town of Gede, they can only go by what they find in their excavations.

Here is a water channel where the townspeople bathed before entering mosques. The city was designed with water in mind with bathrubs and latrines so you can see the issues if the water suddenly dried up:



A short diversion, but an interesting one, nonetheless. Though there’s a ton of history in Kenya, being the Cradle of Mankind and whatnot, there’s not a lot of old architecture. Most settlements, even today, are made with materials that don’t hold up well to the elements. Clay, wood, and palm fronds comprise the vast majority of construction in Kenyan villages. Coral blocks are used by the rich and for the more important structures like mosques, so I guess that mosques are the Kenyan equivalent of the cathedrals in Europe.

It’s still before noon on Saturday! Stay tuned for the rest of the story.

Also, congrats to all of my med school classmates who found out that they matched yesterday! We wish that we were there to celebrate with you. Now that you have a job and more free time, come visit!

Kenya in bloom

One of my favorite things about Kenya is how bright the colors are. The sun is so strong that all the colors seem much more vivid. At noon in Kenya, you actually have no shadow because the sun is directly overhead. It's pretty crazy.

Since the growing season is virtually year-round on the equator, there are amazing flowers all the time. The flowers vary from place to place but all are strikingly bright and beautiful.

The bougainvillea on the coast:






Jacaranda trees up country:





It is one thing I'll certainly miss at home!

Freezer Diving

So here’s what I did last week while M was at the conference:



That’s a -86 degree freezer that I have my head in. I actually got my entire upper body in it at one point. I also managed to freeze off my fingerprints because I was too eager to grab all the boxes I needed and didn’t wear the required ski gloves. I could have waited for one of the Kenyans to come back and help me but patience is not a virtue I possess.

So, what was I freezer diving for you might be thinking? Samples for M’s research. So, in laymen’s terms, the goal of M’s project is to link maternal infection (or lack thereof) while pregnant with the immune response of the babies after they are born. The working hypothesis is that women who were infected with malaria, schistosomiasis, hookworm, etc. while pregnant will have babies who are less able to mount a proper immune response to illness. It seems obvious but no one has proved this point yet; doing so would mean that women in the developing world will actually get treated while pregnant because there’s a cost-benefit in terms of the child’s health and (mostly foreign) aid agencies will pay for it.

So, the project involves testing samples of the babies blood for response childhood vaccinations (hepatitis, H. flu, tetanus, diphtheria) at 6 month intervals from birth to 36 months. All of the babies were born between 2006 and 2008 and they have been collecting blood samples from these babies ever since.

Since the project agreement requires that samples be taken in duplicate, there should be one test tube from each visit in Cleveland and one in Kenya. We were told that the ~3,000 samples M needed were in Kenya; this was not the case. No one is quite sure what happened but somehow all the samples were shipped to Cleveland about 2 weeks before we arrived. Like ships passing in the night, we just missed them.

So, I’m sure you’re thinking this isn’t a big deal, just send them back!!! No can do. There are several people in the lab running different tests on the samples and they were not happy with the idea that they would disappear back to Kenya for a year. So, a plan was developed to take a small amount from each sample and send them back to us. These samples could arrive in waves as people came from the lab every few months. As you can imagine, it’s rather annoying to pipette a small amount from 3,000 tubes into other tubes but it was really the only option. Also, the term for pipetting a small amount is “aliquoting”. Fun fact.

M and his samples:


Unfortunately as the months have gone by, only about 1,200 samples have arrived. Academic research is actually a pretty competitive environment and since very few other people in M’s lab would receive any direct benefit from getting him the samples, they haven’t arrived at quite the pace we had hoped. M has used his time very well, setting up the UTI project, shadowing in the hospital, and doing whatever lab tests he could while he waited but it was looking a bit dire last week.

As we previously mentioned, this week the primary investigators on M’s study were in Kenya and we all sat down to discuss these issues. Our main concern was that M have some publishable research completed by the time we leave so that he can apply to residency programs. After several long meetings, a plan has been devised that involves us running a lot more tests on the samples we have here and hopefully M will get some publishable data from that. We’ve calculated that it’s about 12ish weeks of work for both of us full-time in the lab but obviously I’m happy to help.

His and hers pipetting:


So, why was I freezer diving? Well M’s advisor pointed out that there were 600 follow-ups done last September that hadn’t been sent to Cleveland yet and that if we wanted to go through them to pull out the relevant 50 of them, we could do that. It was all the incentive I needed while he was away! Fifty more is a big increase when you only have 1,200 and I actually netted about 65 so it was a big win.

Urology Conference

The surgery workshop was organized in conjunction with the Kenyan Urology Society annual scientific conference, which capped the week’s activities. I had submitted a research abstract to Dr. Kanyi about a month ago, and he invited me to present it at the meeting! We arrived at the Panafric Hotel, one of the nicest hotels in Nairobi, at about 9:15 for the advertised 9:30 start. I know, not smart with Kenyan time, right? We figured that this would start on time. The conference hall where we were supposed to be holding our meeting was full of pulmonologists discussing asthma. Apparently the hotel had forgotten about our meeting, despite a large exhibit hall filled with pharma reps hawking medicines for BPH (benign prostatic hyperplasia). Oh well. We just relaxed on a large outdoor porch and enjoyed some chai, cookies, and the morning sun.



I spotted the business center, and quickly popped by flashdrive into the computer, as I wanted to a few words on my PowerPoint presentation. All of the files on my flashdrive looked a little weird, and I couldn’t open my presentation! Fortunately, I sent myself the presentation on email, so I just re-downloaded it and saved it on my flashdrive. That worked fine, but I later found out that the business center computer basically erased my flashdrive! All 6 gigabytes! Fortunately I had backed it up a few weeks ago so I didn’t lose too much, but it’s pretty annoying that the business center doesn’t have better virus control. Maybe global health should expand to include computer health care (terrible joke).

At about 11:00 am, we were finally invited to go into the conference hall to get started. Kenya has about 25 urologists, nearly all of whom were in attendance, along with some general surgeons, residents, and nurses. I was the only med student at the conference, we think because the fee for the conference was pretty high (2,000 KSH, or $25). The conference consisted primarily of 15 minute presentations on various research projects that people have been working on. I presented on the rate of urinary tract infection among pregnant women at the hospital where I’m working. It’s just preliminary data right now, but was happy to be able to present and get some ideas from urologists for the follow-up study that we’re about to start.

Amazingly, we made up time and actually finished up at the prescribed time! We then headed over to the Nairobi Club for dinner. This is an old social club built by the Brits over 100 years ago. Lawn bowling? Cricket? A spot of tea? All could be had here. We had the main dining hall for our function. As we were enjoying a beer before dinner, word trickled through that Raila Odinga, the Prime Minister of Kenya, was apparently in the house. I never saw him, but I’ll believe the rumor.



Dinner was good, and afterwards I went back the guesthouse to get some sleep before my early flight back to Mombasa on Saturday morning. All in all, the week was even better than I had expected. Aside from the ambiguity of what we were actually going to do upon arrival, it really couldn’t have gone better. I met a ton of urologists who invited me to visit them at their various hospitals around the country. After seeing the generalist model of care in Msambweni, it was interesting to be part of the more specialized delivery at the tertiary care hospitals in Kenya. Hopefully I’ll have more to report soon!

Currently we have a full house here. Four colleagues are here from the US, so we’re really busy trying to plan for our next (and last) few months here.

Kidney Transplant

On the final day of the surgery workshop, I was invited to help some of the adult urologists with a kidney transplant! KNH is one of only three or so centers in Africa with transplant capabilities. Their first transplant in Kenya was performed in 1978; the recipient was a young gentlemen whose kidney was removed because it was identified as an abdominal mass on an imaging study (he had “horseshoe kidney”, which results when the embryonic kidney fails to split in development). After that first surgery, the poor guy obviously had “renal failure”, but fortunately his loving sister was willing to spare a kidney for him, and they both walked out of the hospital two weeks later (with fantastic spread collar suits and afros, as this was 1978).

I scrubbed for the donor nephrectomy (where they take out the good kidney that is to be transplanted). It didn't do much but retract, but it was really cool to see the process. The kidney is very deep in the back/side, so it takes quite a bit of effort to get good visuals on the slippery guy. While we were harvesting the kidney, a vascular surgeon was preparing the site on the recipient where the kidney was to be attached (it's in the pelvis).

The surgeons freed all around the kidney, ligated any extraneous arteries and veins (such as those going to the adrenal glands which sit on top of the kidneys like little hats), and finally, clamped and cut the renal artery and vein, which supply the bulk of blood to the kidney. The main determinant of graft survival is “ischemia time”, or the amount of time that the kidney isn’t attached to the blood supply. It was definitely short in this case! We got the kidney out, someone ran it over, and by the time we were done closing the incision on the donor, the kidney was in the recipient and already making urine! Pretty amazing.

Rather than an intraoperative picture, which may offend some stomachs, here's a picture of a cute kid:



And part of the team at the end of the day:

Surgery Workshop

After visiting the wards, Dr. Kanyi guided us to the OR locker rooms. We changed into scrubs, and I was treated to size 10 surgical boots, which were fantastic on my size 14 feet. Then, the cases started. The week was dedicated to hypospadias repair. I'm going to briefly explain what this condition is, but if you're squeamish, you might want to skip to the beginning of the next paragraph. Hypospadias is basically when the urethra does not extend to the tip of the penis, but rather opens up somewhere on the underside. It varies case to case; in some boys, the opening is nearly at the proper position and it causes little problem, but in others, the opening can be in the area of the scrotum or even further back, leading to obvious problems with urination and having babies “the fun way”, as one doctor put it. The aim of hypospadias repair is to essentially make a new urethra that opens in the proper place. The difficulty varies depending upon the location.

Over the past few months, the pediatric surgeon has been “saving up” hypospadias cases for this workshop, so we had about 100 patients in-house to “choose from”. The residents decided on about 35 cases that were challenging in different ways, and those were the target to finish during the three days of surgery. About six cases per surgeon per day was a pretty aggressive goal, but the gauntlet was thrown down. Below is part of the team hard at work:



I'll spare the details, but the ensuing three days were very interesting and a great learning opportunity. Since the whole goal of the workshop was teaching, the surgeons basically talked throughout the cases, explaining each and every detail, their thought process, etc, which is awesome as a student. I got permission from the head of the hospital to participate, so I was also able to scrub on some of the surgeries when the Kenyans residents and students were otherwise occupied. I probably saw more hypospadias repairs than I'll see in the entire 5-6 years of my residency; I'm definitely fortunate that I had this opportunity. Here’s me deep in thought during a surgery:



I've been in the OR a fair bit since arriving in Kenya, but this was the first time in a developing world OR for the visiting surgeons. Though they were generally patient, I definitely heard more than once, "I need scissors that cut!". Not an unreasonable request, but sometimes more difficult to find than you'd think.

Kenyatta National Hospital

At 8:00 the next morning, a driver from the hospital picked us up (the two urologists and me) from the hotel (where they were staying. I'm in a much cheaper, but quite cheery guesthouse). The hospital was only a five minute drive away.

Kenyatta National Hospital is the largest hospital in East Africa, and until a larger one was built in Johannesburg, it was the largest in Africa. Built by the British (like many large structures in Kenya), it was actually called King George VI Hospital before independence and was renamed for Jomo Kenyatta, the first President of Kenya. KNH is the main teaching hospital for Kenya's medical students as well.

We were met by Dr. Kanyi, the urologist in charge of the week’s workshops. We then B-lined to the office of the “Med Supe”, or head of the hospital. Here, we were presented to the Med Supe, and he welcomed us to the hospital and gave us permission to work there. We then posed for a photo op, which will probably end up in the IVUmed newsletter, and maybe some Kenyan newspaper. I’ll be on the lookout. I have then take a few shots with my camera, but they all came out extremely awkwardly.



Dr. Kanyi walked us to the ward where the patients awaiting surgery were staying. It was a big room with many beds lined up along the walls, probably about 50 beds in all, with a few tables for nurses right in the middle. Though it looks cramped, it’s actually much roomier than the wards in Msambweni. Mothers and their boys arrived over the weekend, and they’ll stay here through the week waiting for the surgery, and beyond during recovery.



Though things were on a much grander scale at KNH than the hospital in Msambweni, many things were similar. The buildings are in similar states of disrepair. Once structures are built here, I don’t think maintenance or renovation is ever considered, so there are a great many buildings that were once nice, and could be nice again, but money to do the renovation can never be found. The wards are similarly arranged, and primarily run by nurses, though I did notice that doctors visited a lot more frequently. Finally, waiting lists for surgeries is very long, with many patients waiting a year for elective surgeries.

Stay tuned for some surgery action tomorrow!